Treatment Of Primary Spontaneous Pneumothorax Research Articles

Axillary thoracotomy and vats for the treatment of primary spontaneous pneumothorax

Axillary thoracotomy and vats for the treatment of primary spontaneous pneumothorax

New aspects in the diagnosis and treatment of primary spontaneous pneumothorax.

This paper provides a recapitulation of the position of the British Thoracic Society and the American College of Chest Physicians based on a review of the literature concerning the current methods of diagnosing and treating primary spontaneous pneumothorax (PSP). The previously developed guidelines were re-evaluated in 2015 by a task force of the European Respiratory Society (ERS). They are intended to be used by surgeons as well as emergency and pulmonary ward physicians, and they apply largely to emergency procedures. In recent years, the effectiveness of minimally invasive methods (punctures, drainage) in combination with talc pleurodesis for the initial therapy of PSP has been recognized. The efficacy of thoracoscopy (VATS) for the treatment of this disease has been proven by the development of minimally invasive surgical techniques in thoracic surgery. This paper also discusses the efficacy of the surgical methods available.

Treatment of primary spontaneous pneumothorax at a tertiary centre

Treatment of primary spontaneous pneumothorax at a tertiary centre

Transareolar pulmonary bullectomy for primary spontaneous pneumothorax

BackgroundConventional 3-port video-assisted thoracoscopic surgery is the classic approach for the diagnosis and treatment of primary spontaneous pneumothorax. Transareolar pulmonary bullectomy rarely has been attempted. This study aimed to evaluate the feasibility and safety of this novel minimally invasive technique in managing primary spontaneous pneumothorax. MethodsFrom January 2013 to December 2014, a total of 112 male patients with primary spontaneous pneumothorax underwent transareolar pulmonary bullectomy by use of a 5-mm thoracoscope. ResultsAll procedures were performed successfully, with a mean operating time of 26.5 minutes. The mean length of transareolar incision for the main operation was 2.0 ± 0.2 cm, the mean length of incision for the camera port was 0.6 ± 0.1 cm, and the mean postoperative cosmetic score was 3.0 ± 0.8. All patients regained consciousness rapidly after surgery. One hundred seven patients (95.5%) were discharged on postoperative day 2 or 3, with the remainder discharged on postoperative day 4 or 5. Postoperative complications were minor. At 6 months postoperatively, there was no obvious surgical scar on the chest wall, and no patient complained of postoperative pain. No recurrent symptoms were observed. One-year follow-up revealed an excellent cosmetic result and degree of satisfaction. ConclusionsTransareolar pulmonary bullectomy is a safe and effective therapeutic procedure for primary spontaneous pneumothorax caused by pulmonary bullae. The incision is hidden in the areola with excellent cosmetic effects. This novel procedure shows promise as a treatment of primary spontaneous pneumothorax.

Primary spontaneous pneumothorax: simultaneous treatment by bilateral non-intubated videothoracoscopy.

Through a retrospective study, we assessed the feasibility and safety of simultaneous bilateral thoracoscopic wedge resection of blebs or bullae for the treatment of primary spontaneous pneumothorax (PSP) under thoracic epidural anaesthesia with spontaneous ventilation. This retrospective analysis involved a cohort of 37 consecutive patients undergoing simultaneous bilateral thoracoscopic bullectomy under spontaneous ventilation thoracic epidural anaesthesia (n = 15) or intubated general anaesthesia (n = 22) between July 2011 and September 2015. The perioperative data, short-term outcomes and recurrence rates of the two groups were compared. The two groups had comparable preoperative demographic profiles. There were no conversions to thoracotomy or intubated single-lung ventilation. The peak end-tidal carbon dioxide in the non-intubated group was significantly higher than that in the intubated group (mean: 48 vs 34 mmHg, P < 0.001). Both groups had comparable surgical duration, blood loss and lowest intraoperative pulse oxygen saturation level. Postoperatively, the two groups had comparable chest tube duration, volume of fluid administration, length of hospital stay and complication rates. No mortality occurred. The total anaesthesia cost in non-intubated group was significantly lower (mean: CNY 4584 vs 5649, P = 0.016). The mean follow-up was 23.6 ± 12.9 months in the non-intubated group and 21.1 ± 13.4 months in the intubated group. Two recurrent pneumothoraxes in 2 patients were observed after surgical procedures for PSP. One recurrence developed in the non-intubated group (7%) and one in the intubated group (5%). Simultaneous bilateral non-intubated thoracoscopic bullectomy is not only well tolerated and technically feasible but also a safe alternative for selected patients with simultaneous bilateral PSP or with high risk of contralateral recurrence.

Video-assisted thoracoscopic treatment of primary spontaneous pneumothorax in older children and adolescents.

Primary spontaneous pneumothorax (PSP) is a relatively rare condition in the pediatric population lacking of specific recommendations regarding the management. Video-assisted thoracoscopic surgery (VATS) has gained widespread consensus during the last 10 years. We retrospectively reviewed our experience of VATS in the treatment of pediatric patients affected by PSP in terms of timing of surgery, operative technique, and postoperative outcome. Between 1998 and 2014, 58 pediatric patients were treated for PSP. Treatment consisted in pulmonary apicectomy in all patients and pleurodesis. Patients received either apical pleurectomy and mechanical pleurodesis or mechanical pleurodesis alone. Mean age was 16.6 ± 1.6 years (range 10-18) with a male/female ratio of 5:1. Seventeen patients underwent surgery after the first episode of PSP. Apical pleurectomy and mechanical pleurodesis was performed in 30 patients while others received mechanical pleurodesis alone. Conversion to open surgery was needed in four procedures (6.9%). Postoperative complications occurred in 1.7% of cases. Sixteen patients received more than one procedure for contralateral pneumothorax (15 cases) and postoperative recurrence (1 case). The mean follow-up was 95 ± 63 months. Recurrence rate was 12.1%. Univariate analysis showed that recurrence was significantly correlated with younger age (P = 0.044) and postoperative chest tube (P = 0.027). Both univariate and multivariate analysis showed that apical pleurectomy did not prevent recurrences. VATS is an effective procedure for PSP in pediatric patients. Apical pleurectomy does not seem to prevent recurrence. Due to the increased risk of recurrence of PSP in younger patients, indication to VATS after the first episode might be considered. Pediatr Pulmonol. 2016;51:713-716. © 2016 Wiley Periodicals, Inc.

Outcomes of the Tower Crane Technique with a 15-mm Trocar in Primary Spontaneous Pneumothorax.

BackgroundVideo-assisted thoracoscopic surgery (VATS) pulmonary wedge resection has emerged as the standard treatment for primary spontaneous pneumothorax. Recently, single-port VATS has been introduced and is now widely performed. This study aimed to evaluate the outcomes of the Tower crane technique as novel technique using a 15-mm trocar and anchoring suture in primary spontaneous pneumothorax.MethodsPatients who underwent single-port VATS wedge resection in Chungnam National University Hospital from April 2012 to March 2014 were enrolled. The medical records of the enrolled patients were reviewed retrospectively.ResultsA total of 1,251 patients were diagnosed with pneumothorax during this period, 270 of whom underwent VATS wedge resection. Fifty-two of those operations were single-port VATS wedge resections for primary spontaneous pneumothorax performed by a single surgeon. The median age of the patients was 19.3±11.5 years old, and 43 of the patients were male. The median duration of chest tube drainage following the operation was 2.3±1.3 days, and mean postoperative hospital stay was 3.2±1.3 days. Prolonged air leakage for more than three days following the operation was observed in one patient. The mean duration of follow-up was 18.7±6.1 months, with a recurrence rate of 3.8%.ConclusionThe tower crane technique with a 15-mm trocar may be a promising treatment modality for patients presenting with primary spontaneous pneumothorax.

Presenting hydrothorax predicts failure of needle aspiration in primary spontaneous pneumothorax

ObjectiveThe objective was to evaluate if existence of hydrothorax in initial chest radiograph predicts treatment outcome in patients with primary spontaneous pneumothorax who received needle thoracostomy. MethodsThis is a retrospective cohort study carried out from January 2011 to August 2014 in 1 public hospital in Hong Kong. All consecutive adult patients aged 18years or above who attended the emergency department with the diagnosis of primary spontaneous pneumothorax with needle aspiration performed as primary treatment were included. Age, smoking status, size of pneumothorax, previous history of pneumothorax, aspirated gas volume and presence of hydropneumothorax in initial radiograph were included in the analysis. The outcome was success or failure of the needle aspiration. Logistic regression was used to identify the predicting factors of failure of needle aspiration. ResultThere were a total of 127 patients included. Seventy-three patients (57.5%) were successfully treated with no recurrence upon discharge. Among 54 failure cases, 13 patients (10.2%) failed immediately after procedure as evident by chest radiograph and required second treatment. Forty-one patients (32.3%) failed upon subsequent chest radiographs. Multivariate logistic regression showed factors independently associated with the failure of needle aspiration, which included hydropneumothorax in the initial radiograph (odds ratio [OR]=4.47 [1.56i12.83], P=.005), previous history of pneumothorax (OR=3.92 [1.57-9.79], P=.003), and large size of pneumothorax defined as apex-to-cupola distance ≥5cm (OR=2.75 [1.21-6.26], P=.016). ConclusionsHydropneumothorax, previous history of pneumothorax, and large size were independent predictors of failure of needle aspiration in treatment of primary spontaneous pneumothorax.

Is it possible to standardize the treatment of primary spontaneous pneumothorax? Part 1: etiology, symptoms, diagnostics, minimally invasive treatment.

The authors of this report present the history of primary spontaneous pneumothorax (PSP) treatment, its etiology, clinical symptoms, and diagnostic methodology. Further, they discuss minimally invasive methods of treating PSP such as thoracentesis and chemical pleurodesis. They discuss the pros and cons of each method, emphasizing that, according to the international recommendations, they should be used as the first line of treatment for PSP.

Is it possible to standardize the treatment of primary spontaneous pneumothorax? Part 2: surgical methods of treatment.

The present report provides a detailed description of the surgical methods for primary spontaneous pneumothorax (PSP) treatment, from open surgery (thoracotomy) to minimally invasive procedures (video-assisted thoracoscopic surgery – VATS). It describes the methods of preventing pneumothorax recurrence, including partial or complete resection of the parietal pleura and chemical pleurodesis with VATS. The pros and cons of each method are presented. The paper also discusses new techniques for diagnosing pneumothorax, such as fluorescein-enhanced autofluorescence thoracoscopy (FEAT) and infrared thoracoscopy. Finally, the authors propose their own algorithm for the treatment of PSP.

ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax.

Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research.The European Respiratory Society's Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence.Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach.In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required.

Relationship between postoperative bulla neogenesis at the staple line and the resected lung volume in primary spontaneous pneumothorax.

In patients with primary spontaneous pneumothorax (PSP), bullae are generally resected using autosutures under video-assisted thoracoscopic surgery (VATS). However, postoperative bulla neogenesis (POBN) along the staple line is not rare and is a factor promoting PSP recurrence. POBN is attributed to tension along the staple line, and we surmise that the resected lung volume affects this tension. Therefore, in this study, we retrospectively examined the relationship between POBN and the resected lung volume in patients who underwent surgical treatment of PSP. Between February 2011 and May 2015, 70 lung resection sites in 56 PSP patients who underwent primary VATS at our hospital were evaluated. POBN was diagnosed on high-resolution computed tomography 1 year postoperatively in principle. POBN was detected at 26 of 70 (37.1 %) sites. On univariate analysis, lung weight ≥1.5 g, lung length ≥4.0 cm, resected site: apical, age <25 years old and non-smoking habit were identified as significant, and the POBN rates for cases with lung weight ≥1.5 g or lung length ≥4.0 cm were 47.9 % (P = 0.004) and 44.1 % (P < 0.001), respectively. On multivariate analysis, lung weight ≥1.5 g was only significant factor for POBN (P = 0.043). A resected lung weight ≥1.5 g was only significant risk factor of POBN in patients with PSP.

Initial management of primary spontaneous pneumothorax with video-assisted thoracoscopic surgery: a 10-year experience.

First-line conservative treatment of primary spontaneous pneumothorax (PSP) may be challenged by recurrence rates and complications associated with different treatment options. The aim of this study was to evaluate the use of a standardized surgical treatment as 'first-line' treatment. In a 10-year period, 185 patients with PSP were treated with a standardized video-assisted thoracic surgery (VATS) approach including wedge resection and parietal pleurectomy. Data were evaluated retrospectively. All patients with a first event of PSP were included in the study. In addition, follow-up was done by a questionnaire. Mean follow-up period was 70.8 months (±33.5 months). Sub-pleural emphysematous changes were found in every histopathological specimen. In addition, 70.8% had fibrosis of visceral pleura. Recurrence occurred in 4 patients (2.2%). Ten-year freedom from recurrence was 96.2%. Procedure-related morbidity rate was 7.6%. Approximately 85.7% of patients were satisfied with the procedure and the cosmetic result. Three patients died during follow-up (1.6%). Treatment of first episode of PSP by VATS is a safe procedure, with a very low rate of recurrence and a high patient satisfaction. This management of first episode of PSP is based on the underlying pathology. We recommend the use of VATS as the treatment of first choice for patients with PSP.

The effect of pleural abrasion on the treatment of primary spontaneous pneumothorax: a systematic review of randomized controlled trials.

BackgroundPleural abrasion has been widely used to control the recurrence of primary spontaneous pneumothorax (PSP). However, controversy still exists regarding the advantages and disadvantages of pleural abrasion compared with other interventions in preventing the recurrence of PSP.MethodsThe PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched up to December 15, 2014 to identify randomized controlled trials (RCTs) that compared the effects of pleural abrasion with those of other interventions in the treatment of PSP. The study outcomes included the PSP recurrence rate and the occurrence rate of adverse effects.ResultsMechanical pleural abrasion and apical pleurectomy after thoracoscopic stapled bullectomy exhibited similarly persistent postoperative air leak occurrence rates (p = 0.978) and 1-year PSP recurrence rates (p = 0.821), whereas pleural abrasion led to reduced residual chest pain and discomfort (p = 0.001) and a smaller rate of hemothorax (p = 0.036) than did apical pleurectomy. However, the addition of minocycline pleurodesis to pleural abrasion did not reduce the pneumothorax recurrence rate compared with apical pleurectomy (3.8% for both procedures) but was associated with fewer complications. There was no statistical difference in the pneumothorax recurrence rate between mechanical pleural abrasion and chemical pleurodesis with minocycline on either an intention-to-treat basis (4 of 42 versus 0 of 42, p = 0.12; Fisher exact test) or after exclusions (2 of 40 versus 0 of 42, p = 0.24; Fisher exact test). Pleural abrasion plus minocycline pleurodesis also did not reduce the pneumothorax recurrence rate compared with pleural abrasion alone (p = 0.055). Moreover, pleural abrasion plus minocycline pleurodesis was associated with more intense acute chest pain. The postoperative overall recurrence rate in patients who underwent staple line coverage with absorbable cellulose mesh and fibrin glue was similar to that with mechanical abrasion after thoracoscopic bullectomy (13.8% vs. 14.2%, respectively; p = 0.555), but staple line coverage resulted in less postoperative residual pain than mechanical abrasion (0.4% vs.3.2%; p<0.0001). Pleural abrasion after thoracoscopic wedge resection did not decrease the recurrence of pneumothorax compared with wedge resection alone (p = 0.791), but the intraoperative bleeding and postoperative pleural drainage rates were higher when pleural abrasion was performed.ConclusionsIn addition to resulting in the same pneumothorax recurrence rate, thoracoscopic pleural abrasion with or without minocycline pleurodesis is safer than apical pleurectomy in the treatment of PSP. However, minocycline pleurodesis with or without pleural abrasion is not any more effective than pleural abrasion alone. Moreover, additional mechanical abrasion is not safer than additional staple line coverage with absorbable cellulose mesh and fibrin glue after thoracoscopic bullectomy because of increased postoperative pain. Additionally, pleural abrasion after thoracoscopic wedge resection should not be recommended for routine application due to the greater incidence of adverse effects than wedge resection alone. However, further large-scale, well-designed RCTs are needed to confirm the best procedure.

Single-Port Video-Assisted Thoracic Surgery for Primary Spontaneous Pneumothorax

Dear Editor, We read the recent report on “Single-port video-assisted thoracic surgery for primary spontaneous pneumothorax” with great interest [1]. Kang et al. [1] noted that “single-port video-assisted thoracic surgery (VATS) for primary spontaneous pneumothorax had many advantages in terms of the lengths of chest tube drainage and hospital stay, postoperative pain, and paresthesia” [1]. The authors also pointed out that the selection of an appropriate case is the main determinant for success of the procedure. Nevertheless, we would like to draw the reader’s attention to the fact that, despite a good selection, ‘the procedure was accomplished successfully for 92.3% of the patients [2],’ implying a considerable failure rate. In addition, it should be noted that due to the nature of VATS, a slightly higher possibility of recurrence compared to that with standard chest tube thoracostomy can be expected [3]. In conclusion, clinicians should weigh these factors in choosing between single-port VATS and other methods of surgical treatment for primary spontaneous pneumothorax.

Is single port enough in minimally surgery for pneumothorax?

Video-assisted thoracoscopic surgery is a widespread used procedure for treatment of primary spontaneous pneumothorax patients. In this study, the adaptation of single-port video-assisted thoracoscopic surgery approach to primary spontaneous pneumothorax patients necessitating surgical treatment, with its pros and cons over the traditional two- or three-port approaches are examined. Between January 2011 and August 2013, 146 primary spontaneous pneumothorax patients suitable for surgical treatment are evaluated prospectively. Indications for surgery included prolonged air leak, recurrent pneumothorax, or abnormal findings on radiological examinations. Visual analog scale and patient satisfaction scale score were utilized. Forty triple-port, 69 double-port, and 37 single-port operations were performed. Mean age of 146 (126 male, 20 female) patients was 27.1 ± 16.4 (range 15-42). Mean operation duration was 63.59 ± 26 min; 61.7 for single, 64.2 for double, and 63.8 min for triple-port approaches. Total drainage was lower in the single-port group than the multi-port groups (P = 0.001). No conversion to open thoracotomy or 30-day hospital mortality was seen in our group. No recurrence was seen in single-port group on follow-up period. Visual analog scale scores on postoperative 24th, 48th, and 72nd hours were 3.42 ± 0.94, 2.46 ± 0.81, 1.96 ± 0.59 in the single-port group; significantly lower than the other groups (P = 0.011, P = 0.014, and P = 0.042, respectively). Patient satisfaction scale scores of patients in the single-port group on 24th and 48th hours were 1.90 ± 0.71 and 2.36 ± 0.62, respectively, indicating a significantly better score than the other two groups (P = 0.038 and P = 0.046). This study confirms the competency of single-port procedure in first-line surgical treatment of primary spontaneous pneumothorax.

Video-assisted thoracic surgery versus pleural drainage in the management of the first episode of primary spontaneous pneumothorax

BackgroundThe aim of the study was to analyze the cost-effectiveness outcomes of video-assisted thoracic surgery (VATS) in the treatment of primary spontaneous pneumothorax (PSP), comparing the minimally invasive procedure with pleural drainage (PD). MethodsBetween July 2006 and October 2012, we treated 122 patients with a first episode of PSP by VATS (61 patients) or pleural drainage (61 patients). We established the relationship between costs and quality-adjusted life (QAL) for both techniques. ResultsThe total cost per patient of minimally invasive procedure was more advantageous than that of chest tube (€2,422.96 vs €4,855.12). The QAL expectancy of VATS was longer than that of PD (57.00 vs 40.80 at 60 months). The QAL year of VATS (.32 at 1st year and .25 at 5th year) was better than that of PD. Incremental cost-effectiveness ratio of VATS versus PD was between €7,600.00 (1st year) and €10,045.00 (5th year), remaining well below the threshold of acceptability. ConclusionVATS as the first-line treatment for PSP allowed low morbidity, short hospitalization, and excellent quality of life.

Chemical pleurodesis for first presentation of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) most commonly occurs in young, tall, lean males. The PSP recurrence rate varies between 16 and 52 % after the first episode. This high recurrence rate has stimulated the development of different therapeutic approaches, ranging from simple aspiration to invasive therapies, including chemical pleurodesis or surgery. Chemical pleurodesis is a procedure which uses sclerosing agents to cause adhesion between the two layers of the pleura. Traditionally, chemical pleurodesis for PSP has been recommended only if the patient is unwilling or unable to undergo surgery. However, several prospective, randomized trials have shown that additional chemical pleurodesis following simple aspiration or chest tube drainage is a safe and more effective initial treatment for PSP than simple aspiration and drainage alone and significantly reduces pneumothorax recurrence and subsequent thoracic surgery. In this article, the role of chemical pleurodesis in the first presentation of PSP is reviewed.

IODOPOVIDONE PLEURODESIS FOR FIRST PRESENTATION OFPRIMARY SPONTANEOUS PNEUMOTHORAX

Background: The optimal initial management of primary spontaneous pneumothorax (PSP) remains controversial. Aim of the work: Evaluation of the safety and efficacy of intrapleural iodopovidone following intercostal tube drainage for initial treatment of PSP. Patients and Methods: Between June 2010 and June 2014,64 patients with documented first time primary spontaneous pneumothorax were enrolled in this study after obtaining informed consents. They were divided into two groups; Group 1 (control group) were 24 patients have PSP first time and managed by intercostal tube drain without pleurodesis, and group 2 were 40 patients have PSP first time and managed by intercostal tube drain with iodopovidone pleurodesis (20mL of 10% iodopovidone hydrochloride). Results: There was no significant difference between the two groups in terms of demographic data. Also, hospitalization rates and mean hospital stays had no significant difference between both groups. Patients in the iodopovidone group had higher doses of pethidine injection. After a mean follow-up of 9 months (range6-12 months), recurrence was noted in one patient (2.5%) of the iodopovidone group and 7 patients in the control group (29.2%). Conclusion: Intrapleural iodopovidone following intercostal tube drain is a simple, safe and convenient initial treatment for PSP thatreduce the rates of ipsilateral recurrence but associated with significant controllable chestpain.

Transcollation® technique in the thoracoscopic treatment of primary spontaneous pneumothorax.

The already low invasiveness of the thoracoscopic treatment of spontaneous pneumothorax may be further reduced by the transcollation® technique. Herein, we report our further experience with a new device, to coagulate blebs and bullae, compared with contrast to endostapler resection. Data of patients with recurrent or persistent spontaneous pneumothorax, who underwent thoracoscopic treatment, were prospectively collected and reviewed. Those with blebs or bullae (Stages III and IV in accordance with Vanderschueren's classification) were treated with a new device, based on coupling saline solution perfusion with radiofrequency energy. The combination of fluid with radiofrequency allows the sealing of tissue, avoiding charring or burning. Most operations were performed through two 1-cm incisions only. From 2005 to 2010, 73 patients were treated. These were 59 males (80.8%) and 14 females (19.2%), with a mean age of 27.9 years [standard deviation (SD): 11.7]. Forty-three patients underwent general anaesthesia with selective intubation, 9 awake epidural anaesthesia and 21 spontaneous breathing anaesthesia with laryngeal mask. The mean operation time was 31 min (SD: 10.2). The median postoperative drainage period and hospital stay were 2 days (range of 1-11) and 3 days (range of 2-11), respectively. Prolonged air leak occurred in 1 patient (1.4%). Over a mean follow-up period of 60 months (SD: 22.5), two recurrences (2.7%) were reported. The transcollation® technique by cold coagulation of blebs and bullae seems to be effective in the treatment of primary spontaneous pneumothorax. Owing to its potential advantages, it appears to be particularly suitable to be associated with awake epidural and LMA anaesthesia.